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Hemoptysis and Weight Loss in a Smoker Hemoptysis and weight loss in a smoker A 68-year-old woman is brought to the emergency room after *coughing up several tablespoons of bright red blood. For the previous 3 to 4 months, she has had a chronic nonproductive cough but no fevers. More recently, she has noticed some scant blood-streaked sputum. On review of her symptoms, she reports increased fatigue,*decreased appetite, and a 11 kg weight loss in the past 3 months. She denies chest pain, fever, chills, or night sweats. The patient has smoked one pack of cigarettes per day for the past 35 years. She drinks two martinis every day and has not had any significant medical illness. She worked in a library for 35 years and has no history of occupational exposures. She does not take any medication except for one aspirin per day. The patient is a thin woman who is mildly anxious, alert, and oriented. Her blood pressure is 150/90 mm Hg, heart rate 88 bpm, respiratory rate 16 breaths per minute, and temperature 36.5°C. Neck examination reveals no lymphadenopathy, thyromegaly, or carotid bruit. The chest has scattered rhonchi bilaterally, but there are no wheezes or crackles. Cardiovascular examination reveals a regular rate and rhythm, without rubs, gallops, or murmurs. The abdomen is benign with no hepatosplenomegaly. Examination of her extremities reveals no cyanosis; there is*finger clubbing. Neurologic examination is normal. What is your next step? What is the most likely diagnosis? Finger clubbing: loss of the angle between nail and nail fold. CFIM n°38 Hemoptysis MECHANISMS • Neoplasms: Invasion of superficial mucosa and erosion of blood vessels; High vascular tumor with fragile walls • Pulmonary venous hypertension: High Vasculitis pressure damage venous walls • Infection: Inflammation and repeated cough disrupts pulmonary vasculature • Vascular damage by vasculitis or pulmunary infarction MECHANISMS OF UNINTENTIONAL WEIGHT LOSS Thyroid hormones Catecholamines Cytokines Energy balance 3-6 months Malnutrition Universal Screening Tool (MUST) HYPERTROPHIC OSTEOARTHROPATHY AND CLUBBING Hypertrophic osteoarthropathy (HOA) is characterized by clubbing of digits and, in more advanced stages, by periosteal new-bone formation and synovial effusions. Bone changes in the distal extremities begin as periostitis followed by new bone formation. HOA may be primary or secondary associated with intrathoracic malignancies, suppurative and some hypoxemic lung and heart diseases. HOA may be primary or secondary associated with intrathoracic malignancies, suppurative and some hypoxemic lung and heart diseases. Hemoptysis and weight loss in a smoker A 68-year-old woman is brought to the emergency room after *coughing up several tablespoons of bright red blood. For the previous 3 to 4 months, she has had a chronic nonproductive cough but no fevers. More recently, she has noticed some scant blood-streaked sputum. On review of her symptoms, she reports increased fatigue,*decreased appetite, and a 11 kg weight loss in the past 3 months. She denies chest pain, fever, chills, or night sweats. The patient has smoked one pack of cigarettes per day for the past 35 years. She drinks two martinis every day and has not had any significant medical illness. She worked in a library for 35 years and has no history of occupational exposures. She does not take any medication except for one aspirin per day. The patient is a thin woman who is mildly anxious, alert, and oriented. Her blood pressure is 150/90 mm Hg, heart rate 88 bpm, respiratory rate 16 breaths per minute, and temperature 36.5°C. Neck examination reveals no lymphadenopathy, thyromegaly, or carotid bruit. The chest has scattered rhonchi bilaterally, but there are no wheezes or crackles. Cardiovascular examination reveals a regular rate and rhythm, without rubs, gallops, or murmurs. The abdomen is benign with no hepatosplenomegaly. Examination of her extremities reveals no cyanosis; there is*finger clubbing. Neurologic examination is normal. What is your next step? What is the most likely diagnosis? Finger clubbing: loss of the angle between nail and nail fold. CFIM n°38 Hemoptysis and weight loss in a smoker A 68-year-old woman is brought to the emergency room after coughing up several tablespoons of bright red blood. For the previous 3 to 4 months, she has had a chronic nonproductive cough but no fevers. More recently, she has noticed some scant blood-streaked sputum. On review of her symptoms, she reports increased fatigue, decreased appetite, and a 11 kg weight loss in the past 3 months. She denies chest pain, fever, chills, or night sweats. The patient has smoked one pack of cigarettes per day for the past 35 years. She drinks two martinis every day and has not had any significant medical illness. She worked in a library for 35 years and has no history of occupational exposures. She does not take any medication except for one aspirin per day. The patient is a thin woman who is mildly anxious, alert, and oriented. Her blood pressure is 150/90 mm Hg, heart rate 88 bpm, respiratory rate 16 breaths per minute, and temperature 36.5°C. Neck examination reveals no lymphadenopathy, thyromegaly, or carotid bruit. The chest has scattered rhonchi bilaterally, but there are no wheezes or crackles. Cardiovascular examination reveals a regular rate and rhythm, without rubs, gallops, or murmurs. The abdomen is benign with no hepatosplenomegaly. Examination of her extremities reveals no cyanosis; there is finger clubbing. Neurologic examination is normal. What is your next step? Chest imaging, either x-ray and CT scan. If abnormalities are seen, a biopsy procedure to establish a tissue diagnosis. In the meantime, she will benefit from rest and cough suppression to minimize her hemoptysis, which may be acutely life threatening, if massive bleeding occurs. What is the most likely diagnosis? Lung cancer Finger clubbing: loss of the angle between nail and nail fold. CFIM n°38 Lung cancer is the leading cause of cancer deaths in both men and women. * * * * (non-smokers) * * * * * * * * Radiologic Appearance of Lung Cancer. A wedge- shaped density in the middle lobe (a secondary). Also note a coin lesion at the right costophrenic angle. The sharp upper boundary of the middle lobe triangular mass is the middle lobe fissure. The right hilar structures are enlarged by metastases within the hilar lymph nodes. A solitary pulmonary nodule is the most common radiographic presentation of lung cancer. Cancer increases risk of atrial fibrillation Acanthosis nigricans Confusion and lethargy in a patient with lung cancer A 65-year-old white woman is brought to the ER by her family for increasing confusion and lethargy over the past week. She was recently diagnosed with limited stage small cell lung cancer but has not begun cancer treatment. She has not been febrile or had any other recent illnesses. She is not taking any medications. Her blood pressure is 136/82 mm Hg, heart rate is 84 bpm, and respiratory rate is 14 breaths per minute and unlabored. She is afebrile. On examination, she is an elderly appearing woman who is difficult to arouse and reacts only to painful stimuli. She is able to move her extremities without apparent motor deficits, and her deep tendon reflexes are decreased symmetrically. The Glasgow Coma Scale score was 8. The remainder of her examination is normal, with a normal jugular venous pressure and no extremity edema. You order some laboratory tests, which reveal the serum sodium level is 108 mmol/L, potassium 3.8 mmol/L, bicarbonate 24 mEq/L, blood urea nitrogen (BUN) 5 mg/dL, and creatinine 0.5 mg/dL. Serum osmolality is 220 mOsm/kg, and urine osmolality is 400 mOsm/kg. A computed tomographic (CT) scan of the brain shows no masses or hydrocephalus. • What is the most likely diagnosis? • What is your next step in therapy? • What are the complications of therapy? CFIM n° 5 Confusion and lethargy in a patient with lung cancer A 65-year-old white woman is brought to the ER by her family for increasing confusion and lethargy over the past week. She was recently diagnosed with limited stage small cell lung cancer but has not begun cancer treatment. She has not been febrile or had any other recent illnesses. She is not taking any medications. Her blood pressure is 136/82 mm Hg, heart rate is 84 bpm, and respiratory rate is 14 breaths per minute and unlabored. She is afebrile. On examination, she is an elderly appearing woman who is difficult to arouse and reacts only to painful stimuli. She is able to move her extremities without apparent motor deficits, and her deep tendon reflexes are decreased symmetrically. The remainder of her examination is normal, with a normal jugular venous pressure and no extremity edema. You order some laboratory tests, which reveal the serum sodium level is 108 mmol/L, potassium 3.8 mmol/L, bicarbonate 24 mEq/L, blood urea nitrogen (BUN) 5 mg/dL, and creatinine 0.5 mg/dL. Serum osmolality is 220 mOsm/kg, and urine osmolality is 400 mOsm/kg. A computed tomographic (CT) scan of the brain shows no masses or hydrocephalus. • What is the most likely diagnosis? Coma/lethargy secondary to severe hyponatremia, which is most likely caused by a paraneoplastic syndrome of inappropriate secretion of antidiuretic hormone (SIADH). • What is your next step in therapy? Treat the hyponatremia with hypertonic saline • What are the complications of therapy? Osmotic cerebral demyelination, also referred to as central pontine myelinolysis. CFIM n° 5 HYPOVOLEMIA HYPERVOLEMIA EUVOLEMIA Nell’UE Samsca® (tolvaptan) è approvato unicamente per il trattamento di pazienti adulti con iponatriemia secondaria a sindrome da inappropriata secrezione di ormone antidiuretico (SIADH). PATHOGENESIS OF HYPERVOLEMIC-HYPONATRAEMIA IN CIRRHOSIS AND HEARTH FAILURE Heart RAAS failure SNS DIFFERENTIATE BETWEEN: • DILUTIONAL HYPONATREMIA (nonosmotic AVP release, thirst) • DEPLETIONAL HYPONATREMIA (sodium-restricted diet, sodium losses: diuretics, diarrhea, ascites).
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